- Email: [email protected]
Major Bleeding in Patients Treated with Novel Anticoagulants: Prevalence and Predictors
submission to the US Food and Drug Administration for GRAS registration was also assessed. A survey of krill and fish oil prices at a pharmacy chain was conducted on 01/02/2013. Results: The active components of krill and fish oil are the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) which are derived from algae. Fish oil is almost entirely composed of EPA-DHA from triglycerides, whereas in krill oil EPA-DHA exists in both triglyceride and phospholipid forms. Omega-3 in phospholipid has greater absorption (up to 25%). Doses of EPA + DHA of 1000–4000 mg/day lowers triglyceride levels. For primary and secondary prevention threshold doses of 500 mg and 1000 mg, respectively, are recommended. One study showed krill oil lowered total cholesterol by 30%, but two subsequent studies did not. Prices of krill oil were up to 90 times more expensive than fish oil for the equivalent dose of EPA + DHA. Conclusions: Media claims of greater potency of krill oil over fish oil are not substantiated in the literature, nor was it claimed in submission to the FDA. The increased absorption of EPA + DHA in phospholipid form is noted but is not clinically significant. http://dx.doi.org/10.1016/j.hlc.2013.05.521
CSANZ 2013 Abstracts
S219
Results: CSFP patients N = 215 Age (mean ± SD)
53 ± 12
Male
147 (68%)
Median Follow-up Length form Diagnosis (years)
13 IQR 9
Repeat Angiography
42 (25%)
Repeat ED Presentation for Chest Pain
53 (38%)
Repeat Admission for Chest Pain
81 (52%)
Admission for Acute Coronary Syndrome
23 (11%)
Subsequent Acute Myocardial Infarct (AMI)
11 (5%)
Deceased
16 (7%)
Deceased within 5 years of diagnosis
5 (2%)
Conclusion: CSFP patients are more often males, and on-going symptoms requiring hospitalisation is common. Outcomes of patients with the CSFP may not be as favourable as traditionally thought, with 5% of patients suffering AMI and 2% dying within five years. Future studies are required to investigate determinants of adverse outcomes. http://dx.doi.org/10.1016/j.hlc.2013.05.522 521
520
Major Bleeding in Patients Treated with Novel Anticoagulants: Prevalence and Predictors
Long Term Outcomes in Patients with the Coronary Slow Flow Phenomenon
S. Mirzaee 1,∗ , G. Birdsey 2 , J. Amerena 1
L. Khor 1,2,∗ , R. Tavella 1,2 , J. Beltrame 1,2 1 The 2 The
University of Adelaide, Australia Queen Elizabeth Hospital, Australia
Background: The Coronary Slow Flow Phenomenon (CSFP)is a coronary microvascular disorder characterised by normal angiography and delayed opacification of the coronary vessels. Generally these patients are considered to have a good prognosis, despite recurrent chest pain requiring hospitalisation. There is however limited data available on the long-term outcomes of CSFP patients, and considering the persistent morbidity, further evaluation of prognosis is required. Methods: A retrospective case note audit of patients diagnosed with CSFP at two tertiary facilities in South Australia between 1987 and 2012 with a least one-month follow-up available was undertaken. Follow-up data was also obtained via interrogation of hospital administrative databases.
1 Cardiology Research Unit, Barwon Health, Geelong Hospital,
Geelong, Victoria, Australia of Pharmacy, Barwon Health, Geelong Hospital, Geelong, Australia
2 Department
Background: Until recently warfarin was the only effective oral anticoagulant in stroke reduction in high risk patients with non-valvular atrial fibrillation (NVAF). Ischaemic stroke is the most feared and common complication of NVAF. The main safety concern with the use of warfarin and all novel anticoagulants is the risk of major hemorrhage. Methods: This is an observational cross-sectional study of bleeding events associated with novel anticoagulants. The medical record of all patients on novel anticoagulants (Dabigatran and Rivaroxaban) from July 2011 to December 2012 in Barwon Health were reviewed. Result: Haemorrhagic events that required hospitalisation occurred in five (4.2%) of the 119 patients on novel anticoagulants (71 Dabigatran + 48 Rivaroxaban). Overall four (3.36%) had a major bleeding event of which two (1.68%) were life threatening. No mortality associated with haemorrhagic events occurred. The HAS-BLED score before treatment was determined in all of patients who had bleeding (mean score = 3). The mean age 74.2 years old, and all bleeding events occurred in females, four (80%) of five the major bleeding was from the gastro intestinal tract, and three (60%) of five patients who had major bleeding had moderate to severe renal dysfunction at the time of commencement of anticoagulation.
ABSTRACTS
Heart, Lung and Circulation 2013;22:S126–S266
S220
Heart, Lung and Circulation 2013;22:S126–S266
CSANZ 2013 Abstracts
ABSTRACTS
Conclusion: In this observational study the rates of major bleeding with the NOACS was comparable to that seen in the published literature, despite the inappropriate use in several patients with severe renal dysfunction. Thus, to minimise adverse bleeding events with the novel anticoagulant appropriate selection of patients before commencing treatment is crucial.
524 Non-invasive Cardiac Tests are at Least as Good at Predicting Future Adverse Cardiac Events as Coronary Angiography in Kidney Transplant Candidates L. Wang 1,2,∗ , P. Masson 2 , R. Turner 2 , S. Baines 4 , J. Craig 2,5 , A. Webster 2,5
http://dx.doi.org/10.1016/j.hlc.2013.05.523 522
Lord 3 , L.
1 Department
Microbiological Profile of Prosthetic Valve Endocarditis: The Impact of Age and Timing M. Anastasius 1,∗ , C. Ayoub 1 , R. Sy 2 , L. Kritharides 3 1 Cardiology Registrar, Concord Hospital Department of Cardi-
ology, Sydney, NSW, Australia and Consultant Cardiologist, Concord Hospital Department of Cardiology, Sydney, NSW, Australia 3 Head of Deparment, Concord Hospital Cardiology Department, Sydney, NSW, Australia 2 Electrophysiologist
Background: The microbiological profile of prosthetic valve infective endocarditis (PVIE) was examined relative to the timing of infection following index valvular surgery. Methods: Consecutive cases of prosthetic valve endocarditis admitted to all hospitals in NSW between 2000 and 2006 were identified. The collected microbiological data was compared between patients with early (<2 months), intermediate (2–12 months) and late PVIE (>12 months). The effect of age was also examined. Results: There was no statistically significant difference in the microbiological profile of prosthetic valve endocarditis according to the timing of infection relative to index surgery. The major organisms in early PVIE included Staph epidermidis and strep viridans, for intermediate PVIE culture negative and enterococcus and for late PVIE culture negative and Strep viridans. Enterococcus infection occurred exclusively in those above the age of 65 with a significantly higher incidence of late PVIE (p = 0.03). Pathogens
PVIE (Late) (%) N = 50
PVIE (Early) (%) N = 15
p (Chi s.q)
Negative Culture
26.0
S. aureus
12.0
33.3
13.3
0.4
11.1
6.7
MRSA
8.0
0.8
0
0
Staph epidermidis
0.2
4.0
16.7
20.0
0.09
Strep viridans
16.0
11.1
26.7
0.5
Enterococcus
14.0
22.2
13.3
0.7
HACEK
4.0
0
6.7
0.5
Pseudomonas/GNR
2.0
0
0
0.7
Fungal
0
5.6
0
0.1
13.3
0.2
Other (incldiptheria 4 cases, TB)
523 This abstract has been withdrawn
14.0
PVIE (Intermediate) (%) N = 18
0
Conclusion: There was a higher incidence of infection related to Staphylococcus epidermidis in early PVIE. Enterococcus PVIE exclusively occurred in those above the age of 65. These findings aid choice of empirical antibiotics on presentation. http://dx.doi.org/10.1016/j.hlc.2013.05.524
of Cardiology, St. Vincent’s Hospital, Sydney, Australia 2 Sydney School of Public Health, University of Sydney, Australia 3 Department of Cardiology, Freeman Hospital, Newcastleupon-Tyne, United Kingdom 4 Department of Nephrology, Freeman Hospital, Newcastleupon-Tyne, United Kingdom 5 Cochrane Renal Group and Centre for Transplant and Kidney Research, Westmead Hospital, Australia Background: Cardiovascular disease is the leading cause of death following kidney transplantation, and while patients are on the transplant waiting list. Although pretransplant cardiac investigations are routinely performed, the ability of myocardial perfusion scintigraphy (MPS), dobutamine stress echocardiography (DSE) and coronary angiography to predict patients at greatest risk of adverse cardiac outcomes remains unclear. We investigated the ability of these tests to predict all-cause mortality, cardiovascular mortality and major adverse cardiac events (MACE). Methods: MEDLINE and EMBASE data bases (to September 2012) were searched, and risk ratios (RR) and relative risk ratios (RRR) with 95% confidence intervals (CI) calculated for each test and outcome measure using a random effects meta-analysis. Results: Fifty-two studies (7401 participants) contributed data. Abnormal test results were associated with an increased risk of MACE compared with normal results (MPS RR 3.16, 95%CI 1.97–5.06; DSERR 4.62, 95%CI 2.74–7.79; coronary angiography RR 2.83, 95%CI 1.82–4.42). There was weak evidence that abnormal coronary angiography predicted all-cause mortality better than MPS (RRR 0.69, 95%CI 0.49–0.96, P = 0.03) or DSE (RRR 0.72, 95%CI 0.50–1.02, P = 0.06). The prognostic ability of an abnormal non-invasive functional test appeared to be at least as good as coronary angiography for cardiovascular mortality (RRR MPS 0.89, 95%CI 0.38-2.10, P = 0.78; DSE 1.09, 95%CI 0.12–10.05, P = 0.93) and MACE (RRR MPS 1.09, 95%CI 0.64–1.86, P = 0.74; DSE 1.56; 95%CI 0.71–3.45, P = 0.25). Conclusions: Non-invasive cardiac tests are at least as good at predicting future adverse cardiac events as coronary angiography in kidney transplant candidates. http://dx.doi.org/10.1016/j.hlc.2013.05.526
CSANZ 2013 Abstracts
S219
Results: CSFP patients N = 215 Age (mean ± SD)
53 ± 12
Male
147 (68%)
Median Follow-up Length form Diagnosis (years)
13 IQR 9
Repeat Angiography
42 (25%)
Repeat ED Presentation for Chest Pain
53 (38%)
Repeat Admission for Chest Pain
81 (52%)
Admission for Acute Coronary Syndrome
23 (11%)
Subsequent Acute Myocardial Infarct (AMI)
11 (5%)
Deceased
16 (7%)
Deceased within 5 years of diagnosis
5 (2%)
Conclusion: CSFP patients are more often males, and on-going symptoms requiring hospitalisation is common. Outcomes of patients with the CSFP may not be as favourable as traditionally thought, with 5% of patients suffering AMI and 2% dying within five years. Future studies are required to investigate determinants of adverse outcomes. http://dx.doi.org/10.1016/j.hlc.2013.05.522 521
520
Major Bleeding in Patients Treated with Novel Anticoagulants: Prevalence and Predictors
Long Term Outcomes in Patients with the Coronary Slow Flow Phenomenon
S. Mirzaee 1,∗ , G. Birdsey 2 , J. Amerena 1
L. Khor 1,2,∗ , R. Tavella 1,2 , J. Beltrame 1,2 1 The 2 The
University of Adelaide, Australia Queen Elizabeth Hospital, Australia
Background: The Coronary Slow Flow Phenomenon (CSFP)is a coronary microvascular disorder characterised by normal angiography and delayed opacification of the coronary vessels. Generally these patients are considered to have a good prognosis, despite recurrent chest pain requiring hospitalisation. There is however limited data available on the long-term outcomes of CSFP patients, and considering the persistent morbidity, further evaluation of prognosis is required. Methods: A retrospective case note audit of patients diagnosed with CSFP at two tertiary facilities in South Australia between 1987 and 2012 with a least one-month follow-up available was undertaken. Follow-up data was also obtained via interrogation of hospital administrative databases.
1 Cardiology Research Unit, Barwon Health, Geelong Hospital,
Geelong, Victoria, Australia of Pharmacy, Barwon Health, Geelong Hospital, Geelong, Australia
2 Department
Background: Until recently warfarin was the only effective oral anticoagulant in stroke reduction in high risk patients with non-valvular atrial fibrillation (NVAF). Ischaemic stroke is the most feared and common complication of NVAF. The main safety concern with the use of warfarin and all novel anticoagulants is the risk of major hemorrhage. Methods: This is an observational cross-sectional study of bleeding events associated with novel anticoagulants. The medical record of all patients on novel anticoagulants (Dabigatran and Rivaroxaban) from July 2011 to December 2012 in Barwon Health were reviewed. Result: Haemorrhagic events that required hospitalisation occurred in five (4.2%) of the 119 patients on novel anticoagulants (71 Dabigatran + 48 Rivaroxaban). Overall four (3.36%) had a major bleeding event of which two (1.68%) were life threatening. No mortality associated with haemorrhagic events occurred. The HAS-BLED score before treatment was determined in all of patients who had bleeding (mean score = 3). The mean age 74.2 years old, and all bleeding events occurred in females, four (80%) of five the major bleeding was from the gastro intestinal tract, and three (60%) of five patients who had major bleeding had moderate to severe renal dysfunction at the time of commencement of anticoagulation.
ABSTRACTS
Heart, Lung and Circulation 2013;22:S126–S266
S220
Heart, Lung and Circulation 2013;22:S126–S266
CSANZ 2013 Abstracts
ABSTRACTS
Conclusion: In this observational study the rates of major bleeding with the NOACS was comparable to that seen in the published literature, despite the inappropriate use in several patients with severe renal dysfunction. Thus, to minimise adverse bleeding events with the novel anticoagulant appropriate selection of patients before commencing treatment is crucial.
524 Non-invasive Cardiac Tests are at Least as Good at Predicting Future Adverse Cardiac Events as Coronary Angiography in Kidney Transplant Candidates L. Wang 1,2,∗ , P. Masson 2 , R. Turner 2 , S. Baines 4 , J. Craig 2,5 , A. Webster 2,5
http://dx.doi.org/10.1016/j.hlc.2013.05.523 522
Lord 3 , L.
1 Department
Microbiological Profile of Prosthetic Valve Endocarditis: The Impact of Age and Timing M. Anastasius 1,∗ , C. Ayoub 1 , R. Sy 2 , L. Kritharides 3 1 Cardiology Registrar, Concord Hospital Department of Cardi-
ology, Sydney, NSW, Australia and Consultant Cardiologist, Concord Hospital Department of Cardiology, Sydney, NSW, Australia 3 Head of Deparment, Concord Hospital Cardiology Department, Sydney, NSW, Australia 2 Electrophysiologist
Background: The microbiological profile of prosthetic valve infective endocarditis (PVIE) was examined relative to the timing of infection following index valvular surgery. Methods: Consecutive cases of prosthetic valve endocarditis admitted to all hospitals in NSW between 2000 and 2006 were identified. The collected microbiological data was compared between patients with early (<2 months), intermediate (2–12 months) and late PVIE (>12 months). The effect of age was also examined. Results: There was no statistically significant difference in the microbiological profile of prosthetic valve endocarditis according to the timing of infection relative to index surgery. The major organisms in early PVIE included Staph epidermidis and strep viridans, for intermediate PVIE culture negative and enterococcus and for late PVIE culture negative and Strep viridans. Enterococcus infection occurred exclusively in those above the age of 65 with a significantly higher incidence of late PVIE (p = 0.03). Pathogens
PVIE (Late) (%) N = 50
PVIE (Early) (%) N = 15
p (Chi s.q)
Negative Culture
26.0
S. aureus
12.0
33.3
13.3
0.4
11.1
6.7
MRSA
8.0
0.8
0
0
Staph epidermidis
0.2
4.0
16.7
20.0
0.09
Strep viridans
16.0
11.1
26.7
0.5
Enterococcus
14.0
22.2
13.3
0.7
HACEK
4.0
0
6.7
0.5
Pseudomonas/GNR
2.0
0
0
0.7
Fungal
0
5.6
0
0.1
13.3
0.2
Other (incldiptheria 4 cases, TB)
523 This abstract has been withdrawn
14.0
PVIE (Intermediate) (%) N = 18
0
Conclusion: There was a higher incidence of infection related to Staphylococcus epidermidis in early PVIE. Enterococcus PVIE exclusively occurred in those above the age of 65. These findings aid choice of empirical antibiotics on presentation. http://dx.doi.org/10.1016/j.hlc.2013.05.524
of Cardiology, St. Vincent’s Hospital, Sydney, Australia 2 Sydney School of Public Health, University of Sydney, Australia 3 Department of Cardiology, Freeman Hospital, Newcastleupon-Tyne, United Kingdom 4 Department of Nephrology, Freeman Hospital, Newcastleupon-Tyne, United Kingdom 5 Cochrane Renal Group and Centre for Transplant and Kidney Research, Westmead Hospital, Australia Background: Cardiovascular disease is the leading cause of death following kidney transplantation, and while patients are on the transplant waiting list. Although pretransplant cardiac investigations are routinely performed, the ability of myocardial perfusion scintigraphy (MPS), dobutamine stress echocardiography (DSE) and coronary angiography to predict patients at greatest risk of adverse cardiac outcomes remains unclear. We investigated the ability of these tests to predict all-cause mortality, cardiovascular mortality and major adverse cardiac events (MACE). Methods: MEDLINE and EMBASE data bases (to September 2012) were searched, and risk ratios (RR) and relative risk ratios (RRR) with 95% confidence intervals (CI) calculated for each test and outcome measure using a random effects meta-analysis. Results: Fifty-two studies (7401 participants) contributed data. Abnormal test results were associated with an increased risk of MACE compared with normal results (MPS RR 3.16, 95%CI 1.97–5.06; DSERR 4.62, 95%CI 2.74–7.79; coronary angiography RR 2.83, 95%CI 1.82–4.42). There was weak evidence that abnormal coronary angiography predicted all-cause mortality better than MPS (RRR 0.69, 95%CI 0.49–0.96, P = 0.03) or DSE (RRR 0.72, 95%CI 0.50–1.02, P = 0.06). The prognostic ability of an abnormal non-invasive functional test appeared to be at least as good as coronary angiography for cardiovascular mortality (RRR MPS 0.89, 95%CI 0.38-2.10, P = 0.78; DSE 1.09, 95%CI 0.12–10.05, P = 0.93) and MACE (RRR MPS 1.09, 95%CI 0.64–1.86, P = 0.74; DSE 1.56; 95%CI 0.71–3.45, P = 0.25). Conclusions: Non-invasive cardiac tests are at least as good at predicting future adverse cardiac events as coronary angiography in kidney transplant candidates. http://dx.doi.org/10.1016/j.hlc.2013.05.526